Background: There are limited data around sex differences in the risk profile, treatments and outcomes of percu-taneous coronary intervention (PCI) in chronic total occlusion (CTO) lesions in contemporary interventional practice. We investigated the impact of sex on clinical and procedural characteristics, complications and clinical outcomes in a national cohort.Methods & results: We created a longitudinal cohort (2006-2018, n = 30,605) of patients with stable angina who underwent CTO PCI in the British Cardiovascular Intervention Society (BCIS) database. Clinical, demographic, procedural and outcome data were analysed in two groups stratified by sex: male (n = 24,651), female (n = 5954). Female patients were older (68 vs 64 years, P < 0.001), had higher prevalence of diabetes mellitus (DM), hypertension (HTN) and prior stroke. Utilization of intravascular ultrasound (IVUS), drug eluting stents (DES), radial or dual access and enabling strategies during CTO PCI were higher in male compared to female patients. Following multivariable analysis, there was no significant difference in in-patient mortality (adjusted odds ratio (OR):1.40, 95 % CI: 0.75-2.61, P = 0.29) and major cardiovascular and cerebrovascular events (MACCE) (adjusted OR: 1.01, 95 % CI: 0.78-1.29, P = 0.96). The crude and adjusted rates of procedural compli-cations (adjusted OR: 1.37, 95 % CI: 1.23-1.52, P < 0.001), coronary artery perforation (adjusted OR: 1.60, 95 % CI: 1.26-2.04, P < 0.001) and major bleeding (adjusted OR: 2.06, 95 % CI: 1.62-2.61, P < 0.001) were higher in women compared with men.Conclusion: Female patients treated by CTO PCI were older, underwent lesser complex procedures, but had higher adjusted risk of procedural complications with a similar adjusted risk of mortality and MACCE compared with male patients.(c) 2022 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

Background Long lesions are known to have worse outcomes following percutaneous coronary intervention (PCI), but there are limited data assessing the association between lesion length and clinical outcomes in PCI procedures undertaken in chronic total occlusions (CTO). Methods and results We formed a longitudinal cohort (2006-2018, n = 27,205) of stable angina patients who underwent PCI to CTO in the British Cardiovascular Intervention Society (BCIS) database. Clinical, demographical, procedural, and outcome data were analyzed in three groups by treated segment length, < 30 mm (n = 11,782), 30-59 mm (n = 10,415), >= 60 mm (n = 5008). Prevalence of previous myocardial infarction and PCI were higher in patients in 30-59 mm group or >= 60 mm group compared with < 30 mm group. Following multivariable analysis, no significant difference was observed in in-patient death (OR = 30-59 mm group = 1.10, CI:0.55-2.19, p = 0.78) (OR >= 60 mm group = 0.82, CI: 0.33-2.05, p = 0.67), and 1-year death (OR = 30-59 mm group = 1.06, CI: 0.81-1.37, p = 0.69) (OR >= 60 mm group =1.01, CI: 0.70-1.43, p = 0.99) (< 30 mm group = reference) but in-patient MACE was higher in > = 60 mm group (OR: 1.52, CI: 1.15-2.01, p = 0.06) but similar in 30-59 mm group (OR: 1.16, CI: 0.91-1.48, p = 0.22) compared with < 30 mm group. The adjusted rates of procedural complications were higher in >= 60 mm group (OR: 1.61, CI: 1.40-1.85, p < 0.001) but were similar in 30-59 mm group (OR: 1.06, CI: 0.94-1.20, p < 0.31) compared with < 30 mm group. For every 10 mm increase, there was an increased adjusted risk of in-patient procedural complications and coronary perforation but not in-patient MACE or death. Conclusion Patients with very long CTO lesions have higher risk of procedural complications and in-patient MACE but similar risk of short or long-term mortality compared with short CTO lesions.

A 64 year old male was brought to a tertiary cardiac centre following collapse preceded by central chest pain and presyncope. On arrival the patient had ventricular fibrillation with return of spontaneous circulation after one direct current cardioversion with a resulting blood pressure of 50/30 mmHg. Past history is hypertension, hypothyroidism and smoking.Electrocardiogram showed sinus rhythm with widespread ST depression but ST elevation in aVR.The patient was taken directly to the cardiac catheter laboratory and found to have critical distal left main stem (LMS) disease. Ostially occluded left anterior descending (LAD) with heavy calcification. Dominant left circumflex (LCx) with heavy proximal calcification and occlusion. Critical proximal ramus disease. The right coronary was not imaged. An intra-aortic balloon pump (IABP) was placed via the right femoral artery. Heparin and tirofiban were given. A 7F EBU guide engaged via the right radial artery. Wires were advanced down LAD and LCx and semi-compliant balloons were inflated in each limb, and although constrained, successfully restored flow. Intravascular ultrasound (IVUS) showed nodular and concentric LAD ostial and concentric LCx calcification. The LAD wire was exchanged via microcatheter for a rotawire and LCx wire removed. 1.75 mm burr rotablation was performed with multiple runs and different guide angles between 140 and 170 thousand revolutions per minute to LMS-LAD. The ramus was wired, pre-dilated and treated with a drug coated balloon. Shockwave intra-vascular lithotripsy to LAD and LCx. Following pre-dilatation with non-compliant balloons the patient received LMS-LAD-LCx culotte bifurcation PCI with Megatron drug eluting stents (DES) using 6 mm balloon for LMS optimisation. Following sequential then kissing balloon inflations, IVUS showed under-expansion of the LCx stent and distal stent edge plaque. A synergy DES was placed to cover the distal stent edge. Further post dilatation and final kissing inflation was undertaken. Final minimum stent area; LMS 18 mm2, LAD 12 mm2 and LCx 9 mm2 with TIMI 3 flow. Minor nipping of ramus ostium was accepted. The patient had a period of recovery on the coronary care unit with dobutamine and IABP support. This was weaned over 36 hours and he went on to make a full clinical recovery.Rotational atherectomy is typically avoided in STEMI due to risk of no-reflow. Given the acuity of the clinical scenario and the challenging bulk of calcium seen it was felt the benefits of this technique outweighed the risks. Rotational atherectomy provides treatment to superficial calcium and shockwave therapy added further, deeper, calcium modification. This case demonstrates the role of RotaShock in primary percutaneous coronary intervention. In this case we were able to perform complex calcium modification techniques in a patient in extremis requiring mechanical circulatory support with excellent radiological and ultimately clinical result. Conflict of Interest No conflicts to declare.

To describe the utility and safety of intravascular lithotripsy (IVL) in the setting of primary percutaneous coronary intervention (PCI) for ST elevation myocardial infarction (STEMI).

This study aimed to present a case series of patient treated for stent underexpansion resistant to conventional treatment with intravascular lithotripsy (IVL).

BACKGROUND:The impact of COVID-19 on the diagnosis and management of nonculprit lesions remains unclear. OBJECTIVES:This study sought to evaluate the management and outcomes of patients with nonculprit lesions during the COVID-19 pandemic. METHODS:We conducted a retrospective observational analysis of consecutive primary percutaneous coronary intervention (PPCI) pathway activations across the heart attack center network in London, UK. Data from the study period in 2020 were compared with prepandemic data in 2019. The primary outcome was the rate of nonculprit lesion percutaneous coronary intervention (PCI) and secondary outcomes included major adverse cardiovascular events. RESULTS:A total of 788 patients undergoing PPCI were identified, 209 (60%) in 2020 cohort and 263 (60%) in 2019 cohort had nonculprit lesions (p = .89). There was less functional assessment of the significance of nonculprit lesions in the 2020 cohort compared to 2019 cohort; in 8% 2020 cohort versus 15% 2019 cohort (p = .01). There was no difference in rates of PCI for nonculprit disease in the 2019 and 2020 cohorts (31% vs 30%, p = .11). Patients in 2020 cohort underwent nonculprit lesion PCI sooner than the 2019 cohort (p < .001). At 6 months there was higher rates of unplanned revascularization (4% vs. 2%, p = .05) and repeat myocardial infarction (4% vs. 1%, p = .02) in the 2019 cohort compared to 2020 cohort. CONCLUSION:Changes to clinical practice during the COVID-19 pandemic were associated with reduced rates of unplanned revascularization and myocardial infarction at 6-months follow-up, and despite the pandemic, there was no difference in mortality, suggesting that it is not only safe but maybe more efficacious.

Aims: Coronary intravascular lithotripsy (IVL) is a novel approach to vascular calcium modification that restores vessel compliance allowing effective lesion expansion. In this study we report the capacity for coronary IVL to precipitate ventricular ectopics ("shocktopics") and asynchronous cardiac pacing. Methods and results: This was a retrospective review of all cases of coronary IVL (n=54) undertaken in the Royal Victoria Hospital, Belfast, between September 2018 and March 2019. The indication for PCI was chronic stable angina in 46.1% (n=26), non-ST-elevation acute coronary syndrome (NSTEACS) in 33.3% (n=18) and ST-elevation myocardial infarction (STEMI) in 18.5% (n=10) of patients. The incidence of coronary IVL-provoked ventricular capture was 77.8% (n=42). Multivariable logistic regression analysis identified heart rate as the only independent predictor of an increased risk of IVL-induced ventricular capture. Patients with a heart rate <65 bpm prior to IVL were sixteen-fold more likely (OR 16.3 [2.4-110.8], p=0.004) to experience events compared to patients with a heart rate >= 65 bpm. "Shocktopic" beat morphology was largely uniform in each patient and appeared dependent on the target lesion location, in keeping with mechano-electric coupling through activation of local stretch-activated cardiomyocyte channels. No adverse clinical events occurred as a result of coronary IVL-induced capture. Conclusions: Coronary IVL with the Shockwave Medical system is associated with a high incidence of "shocktopics" and asynchronous cardiac pacing that is largely dependent on the resting heart rate. There have been no clinical events associated with this phenomenon, but further systematic evaluation is warranted.

The effects of serelaxin, a recombinant form of human relaxin-2 peptide, on vascular function in the coronary microvascular and systemic macrovascular circulation remain largely unknown. This mechanistic, clinical study assessed the effects of serelaxin on myocardial perfusion, aortic stiffness, and safety in patients with stable coronary artery disease (CAD).

Objective: PAR (protease-activated receptor)-4 antagonism has antiplatelet effects under conditions of high shear stress. We aimed to establish whether PAR4 antagonism had additive antithrombotic activity in the presence of factor Xa inhibition in an ex vivo model of acute arterial injury. Approach and Results: Fifteen healthy volunteers (29 +/- 6 years, 7 women) completed a phase zero double-blind randomized controlled crossover trial. Ex vivo platelet activation, platelet aggregation, and thrombus formation were measured following blood perfusion of low shear and high shear stress chambers. Upstream of the chambers, extracorporeal blood was admixed with (1) vehicle, (2) low-dose apixaban (20 ng/mL), (3) high-dose apixaban (80 ng/mL), (4) BMS-986141 (400 ng/mL), (5) BMS-968141 and low-dose apixaban, or (6) BMS-968141 and high-dose apixaban in 6 sequential studies performed in random order. Compared with vehicle, BMS-986141 demonstrated selective inhibition of PAR4-AP (agonist peptide)-stimulated platelet aggregation, platelet-monocyte aggregates, and P-selectin expression (P <= 0.01 for all). Total thrombus area was reduced under both low shear and high shear stress conditions for all drug infusions (P0.0001 for all versus vehicle). BMS-968141 reduced total (<= 44.4%) and platelet-rich (<= 39.3%) thrombus area, whereas apixaban reduced total (<= 42.9%) and fibrin-rich (<= 31.6%) thrombus area. Combination of BMS-986141 with apixaban caused a further modest reduction in total thrombus area (9.6%-12.4%), especially under conditions of high shear stress (P <= 0.027). Conclusions: In the presence of factor Xa inhibition, PAR4 antagonism with BMS-986141 further reduces thrombus formation, especially under conditions of high shear stress. This suggests the potential for additive efficacy of combination PAR4 antagonism and factor Xa inhibition in the prevention of atherothrombotic events. Graphic Abstract: A is available for this article.

Objectives To understand the impact of COVID-19 on delivery and outcomes of primary percutaneous coronary intervention (PPCI). Furthermore, to compare clinical presentation and outcomes of patients with ST-segment elevation myocardial infarction (STEMI) with active COVID-19 against those without COVID-19.Methods We systematically analysed 348 STEMI cases presenting to the PPCI programme in London during the peak of the pandemic (1 March to 30 April 2020) and compared with 440 cases from the same period in 2019. Outcomes of interest included ambulance response times, timeliness of revascularisation, angiographic and procedural characteristics, and in-hospital clinical outcomesResults There was a 21% reduction in STEMI admissions and longer ambulance response times (87 (62–118) min in 2020 vs 75 (57–95) min in 2019, p<0.001), but that this was not associated with a delays in achieving revascularisation once in hospital (48 (34–65) min in 2020 vs 48 (35–70) min in 2019, p=0.35) or increased mortality (10.9% (38) in 2020 vs 8.6% (38) in 2019, p=0.28). 46 patients with active COVID-19 were more thrombotic and more likely to have intensive care unit admissions (32.6% (15) vs 9.3% (28), OR 5.74 (95%CI 2.24 to 9.89), p<0.001). They also had increased length of stay (4 (3–9) days vs 3 (2–4) days, p<0.001) and a higher mortality (21.7% (10) vs 9.3% (28), OR 2.72 (95% CI 1.25 to 5.82), p=0.012) compared with patients having PPCI without COVID-19.Conclusion These findings suggest that PPCI pathways can be maintained during unprecedented healthcare emergencies but confirms the high mortality of STEMI in the context of concomitant COVID-19 infection characterised by a heightened state of thrombogenicity.

OBJECTIVES:The aim of this study was to assess angiographic, imaging, and clinical outcomes following chronic total occlusion (CTO) percutaneous coronary intervention (PCI) with dissection and re-entry techniques (DART) and subintimal (SI) stenting compared with intimal techniques.BACKGROUND:Reliable procedural success and safety in CTO PCI require the use of DART to treat the most complex patients. Potential concerns regarding the durability of DART with SI stenting still need to be addressed.METHODS:This was a prospective, multicenter, single-arm trial of patients with appropriate indications for CTO PCI.RESULTS:Successful CTO PCI was performed in 210 of 231 patients (91% success). At 1 year, the primary endpoint of target vessel failure (cardiac death, myocardial infarction related to the target vessel, or any ischemia-driven revascularization) occurred in 5.7% of patients, meeting the pre-set performance goal. Major adverse cardiovascular events (all-cause mortality, myocardial infarction, or target vessel revascularization) occurred in 10% at 1 year and 17% by 2 years and was not influenced by DART. Quality-of-life measures significantly improved from baseline to 12 months. There was no difference in intravascular healing assessed using optical coherence tomography at 12 months for patients treated with DART and SI stenting compared with intimal strategies.CONCLUSIONS:Contemporary CTO PCI is associated with medium-term clinical outcomes comparable with those achieved in other complex PCI cohorts and significant improvements in quality of life. The use of DART with SI stenting does not adversely affect intravascular healing at 12 months or medium-term major adverse cardiovascular events. (Consistent CTO Trial; NCT02227771).

AIMS Coronary intravascular lithotripsy (IVL) is a novel approach to vascular calcium modification that restores vessel compliance allowing effective lesion expansion. In this study we report the capacity for coronary IVL to precipitate ventricular ectopics ("shocktopics") and asynchronous cardiac pacing. METHODS AND RESULTS This was a retrospective review of all cases of coronary IVL (n=54) undertaken in the Royal Victoria Hospital, Belfast between 12th September 2018 and 1st March 2019. The indication for PCI was chronic stable angina in 46.1% (n=26), non-ST elevation acute coronary syndrome (NSTEACS) in 33.3% (n=18) and ST-elevation myocardial infarction (STEMI) in 18.5% (n=10) of patients. The incidence of coronary IVL provoked ventricular capture was 77.8% (n=42). Multivariable logistic regression analysis identified heart rate as the only independent predictor of an increased risk of IVL induced ventricular capture. Patients with a heart rate < 65 bpm prior to IVL were sixteen-fold more likely (OR 16.3 [2.4-110.8], p=0.004) likely to experience events compared to patients with a heart ≥ 65. "Shocktopic" beat morphology was largely uniform in each patient and appeared dependent on the target lesion location, in keeping with mechano-electric coupling through activation of local stretchactivated cardiomyocyte channels. No adverse clinical events occurred as a result of coronary IVL induced capture. CONCLUSIONS Coronary IVL with the Shockwave Medical system is associated with a high incidence of "shocktopics" and asynchronous cardiac pacing that is largely dependent on the resting heart rate. There have been no clinical events associated with this phenomenon, but further systematic evaluation is warranted.

Introduction Intravascular lithotripsy (IVL; Shockwave Medical, Santa Clara, CA, USA) is a new treatment for coronary artery calcification (CAC) that may offer advantages over existing balloon-based therapies and atherectomy devices. Use of IVL in calcific non-left main (LM) disease has been shown to be safe with high acute gain and low residual stenosis1. Similar benefits might be expected in patients with calcific distal LM disease but have yet to be reported. Methods This was a retrospective analysis of all patients with obstructive calcific distal LM (or equivalent) disease treated with IVL in three tertiary centres between ...

Aims The effects of serelaxin, a recombinant form of human retaxin-2 peptide, on vascular function in the coronary microvascular and systemic macrovascular circulation remain largely unknown. This mechanistic, clinical study assessed the effects of serelaxin on myocardial perfusion, aortic stiffness, and safety in patients with stable coronary artery disease (CAD). Methods and results In this multicentre, double-blind, parallel-group, placebo-controlled study, 58 patients were randomized 1:1 to 48 h intravenous infusion of serelaxin (30 mu g/kg/day) or matching placebo. The primary endpoints were change from baseline to 47 h post-initiation of the infusion in global myocardial perfusion reserve (MPR) assessed using adenosine stress perfusion cardiac magnetic resonance imaging, and apptanation tonometry-derived augmentation index (Alx). Secondary endpoints were: change from baseline in Alx and pulse wave velocity, assessed at 47 h, Day 30, and Day 180; aortic distensibility at 47h; pharmacokinetics and safety. Exploratory endpoints were the effect on cardiorenal biomarkers [N-terminal pro-brain natriuretic peptide (NT-proBNP), high-sensitivity troponin T (hsTnT), endothelin-1, and cystatin C]. Of 58 patients, 51 were included in the primary analysis (serelaxin, n = 25; placebo, n= 26). After 2 and 6 h of serelaxin infusion, mean placebo-corrected blood pressure reductions of -9.6 mmHg (P = 0.01) and -13.5 mmHg (P = 0.0003) for systolic blood pressure and -5.2 mmHg (P = 0.02) and -8.4 mmHg (P = 0.001) for diastolic blood pressure occurred. There were no between-group differences from baseline to 47 h in global M PR (-0.24 vs. -0.13, P = 0.44) or Alx (3.49% vs. 0.04%, P=0.21) with serelaxin compared with placebo. Endothelin-1 and cystatin C levels decreased from baseline in the serelaxin group, and there were no clinically relevant changes observed with serelaxin for NT-proBNP or hsTnT. Similar numbers of serious adverse events were observed in both groups (serelaxin, n = 5; placebo, n = 7) to 180-day follow-up. Conclusion In patients with stable CAD, 48 h intravenous serelaxin reduced blood pressure but did not alter myocardial perfusion.

HomeCirculation: Cardiovascular InterventionsVol. 13, No. 7Effect of the COVID-19 Pandemic on ST-Segment–Elevation Myocardial Infarction Presentations and In-Hospital Outcomes Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBEffect of the COVID-19 Pandemic on ST-Segment–Elevation Myocardial Infarction Presentations and In-Hospital Outcomes Simon J. Wilson, Michelle J. Connolly, Ziyad Elghamry, Claudia Cosgrove, Sami Firoozi, Pitt Lim, Rajan Sharma and James C. Spratt Simon J. WilsonSimon J. Wilson Correspondence to: Simon J. Wilson, MBCHB, Cardiovascular Department, St. George's Hospitals and University Foundation NHS Trust, London, United Kingdom. Email E-mail Address: [email protected] https://orcid.org/0000-0002-1999-5103 Department of Cardiology, St. George's University Foundation Hospitals NHS Trust, London, United Kingdom. , Michelle J. ConnollyMichelle J. Connolly Department of Cardiology, St. George's University Foundation Hospitals NHS Trust, London, United Kingdom. , Ziyad ElghamryZiyad Elghamry Department of Cardiology, St. George's University Foundation Hospitals NHS Trust, London, United Kingdom. , Claudia CosgroveClaudia Cosgrove Department of Cardiology, St. George's University Foundation Hospitals NHS Trust, London, United Kingdom. , Sami FirooziSami Firoozi Department of Cardiology, St. George's University Foundation Hospitals NHS Trust, London, United Kingdom. , Pitt LimPitt Lim Department of Cardiology, St. George's University Foundation Hospitals NHS Trust, London, United Kingdom. , Rajan SharmaRajan Sharma Department of Cardiology, St. George's University Foundation Hospitals NHS Trust, London, United Kingdom. and James C. SprattJames C. Spratt Department of Cardiology, St. George's University Foundation Hospitals NHS Trust, London, United Kingdom. Originally published30 Jun 2020https://doi.org/10.1161/CIRCINTERVENTIONS.120.009438Circulation: Cardiovascular Interventions. 2020;13:e009438Preliminary reports suggest there has been a marked reduction in the number of patients presenting with acute ST-segment–elevation myocardial infarction (STEMI) during the coronavirus disease 2019 (COVID-19) pandemic.1–3 However, the available data are limited. Moreover, it remains to be determined what effect COVID-19 has had on STEMI in-hospital outcomes. Here we report changes in presentation and prognostic markers in patients admitted to our institution with STEMI following the outbreak of COVID-19.Index admission data were collected on all patients referred for primary percutaneous coronary intervention (PPCI) to our tertiary cardiac center between February 19 and April 14 for the past 4 consecutive years. The COVID-19 era was defined as March 18, 2020, onward, corresponding to the introduction of restrictions of movement and a public health drive to combat rising cases in the United Kingdom. Poisson regression modeling was used to estimate the impact of COVID-19 on weekly number of PPCI referrals, cardiac catherization laboratory (cath-lab) activations, and true STEMI numbers adjusting for calendar week and year. To further investigate the impact on in-hospital survival, the observed-to-predicted mortality ratio was determined using the US National Cardiovascular Data Registry risk calculator. Effect on time to call for help from symptom onset (early, <4 hours; delayed, 4–12 hours; late, >12 hours), in-hospital mortality, percentage of PPCI referrals resulting in cath-lab activation, and percentage of cath-lab activations resulting in STEMI diagnosis were assessed by the χ2 test. Mean difference in index admission echocardiogram-derived quantitatively determined left ventricular ejection fraction was examined by an unpaired t test. A two-sided P of <0.05 was considered statistically significant. All calculations were performed using the statistical package R (www.R-project.org). The study was conducted in accordance with local ethic guidelines with all procedures undertaken as part of standard care and informed consent provided. The data, analytical methods, and study materials will be made available upon reasonable request.Across the 8-week window, the total number of PPCI referrals, cath-lab activations, and STEMI presentations were 952, 441, and 388, respectively. Compared with before COVID-19, incidence rate ratios showed weekly PPCI referrals in the COVID-19 era decreased by a factor of 42.8% ([95% CI, 23.7%–57.6%]; P<0.001), cath-lab activations by 53.1% ([95% CI, 27.7%–70.1%]; P<0.001), and STEMI presentations by 51.4% ([95% CI, 23.6%–70.2%]; P=0.002; Figure [A]). Time to call for help was significantly longer in the COVID-19 era with more patients presenting either delayed or late (Figure [B]). The percentage of PPCI referrals triggering cath-lab activation (46.5% versus 41.5%; P=0.45) and cath-lab activations resulting in STEMI diagnosis (87.4% versus 92.6%; P=0.56) did not change.Download figureDownload PowerPointFigure. Impact of coronavirus disease 2019 (COVID-19) on ST-segment–elevation myocardial infarction (STEMI) presentations and in-hospital outcomes. Impact of COVID-19 on (A) weekly primary percutaneous coronary intervention (PPCI) referrals, coronary catheterization laboratory (cath-lab) activations, and STEMI numbers, (B) time from symptom onset to call for help for all cath-lab activations, (C) left ventricular ejection fraction in STEMI admissions (box, median and interquartile range; whiskers, minimum to maximum), and (D) in-hospital mortality in STEMI admissions.The left ventricular ejection fraction of STEMI patients was significantly lower in the COVID-19 era (43.7% versus 47.4%; P=0.02; Figure [C]) with data available in 97% and 94% of patients, respectively. There was a numerical increase in STEMI in-hospital mortality that did not reach significance (14.5% versus 11.0%; P=0.47; Figure [D]) while the observed-to-predicted mortality ratios remained comparable (1.69 versus 1.83). None of the STEMI patients who died tested positive for COVID-19, and baseline characteristics were similar before and during the outbreak (age, 64.8 versus 63.0 years; male, 78.1% versus 67.9%; diabetes mellitus, 18.6% versus 14.3%; creatinine, 94.3 versus 82.1 μmol/L; preprocedure cardiogenic shock, 18.6% versus 17.9%; and anterior infarct, 47.9% versus 57.1%; P>0.2 for all).Recent data from the United States have suggested a major decline in STEMI activations during the early phase of COVID-19.1 However, it is unclear whether this reflected a true reduction in STEMI presentations or a decrease in inappropriate referrals/cath-lab activations. Coincident with a rise in COVID-19 in the United Kingdom and the introduction of social distancing measures, we observed a fall of ≈50% in both cath-lab activations and STEMI admissions. Comparing the COVID-19 era to historic data, there was no change in the relative number of inappropriate PPCI referrals or false cath-lab activations. Thus, our data indicate the occurrence of a true decline in STEMI presentations with a similar fall in STEMI numbers reported in Europe.2Besides a reduction in STEMI admissions, we observed a striking change in presentation and prognostic indicators. Time to call for help lengthened considerably with more than a 3-fold increase in the number of patients presenting late. This is in line with evidence that falls in STEMI admission are being driven, at least in part, by behavior change.4 The impact of this delay to presentation is a major concern with STEMI patients admitted in the COVID-19 era found to have a significantly worse left ventricular ejection fraction than before the outbreak. This reduction in left ventricular ejection fraction will be likely to translate to increased future morbidity and mortality.5 Indeed, we observed a numerical increase in STEMI in-hospital mortality not explained by intercurrent COVID-19 illness or changes in baseline characteristics, although it should be emphasized the difference was nonsignificant.In conclusion, we have shown a substantial decline in STEMI presentations since the outbreak of COVID-19 and demonstrate for the first time an increase in markers of adverse prognosis. Our results indicate a high potential for major cardiac collateral damage during the COVID-19 pandemic and support measures to combat this where possible.Sources of FundingNone.DisclosuresNone.FootnotesFor Sources of Funding and Disclosures, see page 3.Correspondence to: Simon J. Wilson, MBCHB, Cardiovascular Department, St. George's Hospitals and University Foundation NHS Trust, London, United Kingdom. Email simonwilson3@nhs.netReferences1. Garcia S, Albaghdadi MS, Meraj PM, Schmidt C, Garberich R, Jaffer FA, Dixon S, Rade JJ, Tannenbaum M, Chambers J, et al. Reduction in ST-segment elevation cardiac catheterization laboratory activations in the United States during COVID-19 pandemic.J Am Coll Cardiol. 2020; 75:2871–2872. doi: 10.1016/j.jacc.2020.04.011CrossrefMedlineGoogle Scholar2. Metzler B, Siostrzonek P, Binder RK, Bauer A, Reinstadler SJ. Decline of acute coronary syndrome admissions in Austria since the outbreak of COVID-19: the pandemic response causes cardiac collateral damage.Eur Heart J. 2020; 41:1852–1853. doi: 10.1093/eurheartj/ehaa314CrossrefMedlineGoogle Scholar3. Rodríguez-Leor O, Cid-Álvarezd B, Ojeda S, Martín-Moreiras J, Rumoroso JR, López-Palop R, Serrador A, Cequier A, Romaguera R, Cruz I, et al. Impact of the COVID-19 pandemic on interventional cardiology activity in Spain.REC Interv Cardiol. 2020; 2:82–89.Google Scholar4. Tam CF, Cheung KS, Lam S, Wong A, Yung A, Sze M, Lam YM, Chan C, Tsang TC, Tsui M, et al. Impact of coronavirus disease 2019 (COVID-19) outbreak on ST-segment-elevation myocardial infarctionare in Hong Kong, China.Circ Cardiovasc Qual Outcomes. 2020; 13:e006631. doi: 10.1161/CIRCOUTCOMES.120.006631LinkGoogle Scholar5. Burns RJ, Gibbons RJ, Yi Q, Roberts RS, Miller TD, Schaer GL, Anderson JL, Yusuf S; CORE Study Investigators. The relationships of left ventricular ejection fraction, end-systolic volume index and infarct size to six-month mortality after hospital discharge following myocardial infarction treated by thrombolysis.J Am Coll Cardiol. 2002; 39:30–36. doi: 10.1016/s0735-1097(01)01711-9CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Hernandez I, Yang L, Tang S, Cameron T, Guo J, Gabriel N, Essien U, Magnani J and Gellad W (2024) COVID-19 pandemic and trends in clinical outcomes and medication use for patients with established atrial fibrillation: A nationwide analysis of claims data, American Heart Journal Plus: Cardiology Research and Practice, 10.1016/j.ahjo.2024.100396, 42, (100396), Online publication date: 1-Jun-2024. 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July 2020Vol 13, Issue 7 Advertisement Article InformationMetrics © 2020 American Heart Association, Inc.https://doi.org/10.1161/CIRCINTERVENTIONS.120.009438PMID: 32600109 Originally publishedJune 30, 2020 Keywordshospital mortalitypandemicsprognosispublic healthstroke volumePDF download Advertisement SubjectsPercutaneous Coronary Intervention

•IIn patients with saphenous vein graft (SVG) failure, PCI of the native vessel is undertaken to facilitate more durable results.•However, if the SVG remains patent, residual competitive flow presents a potential risk for early target lesion failure (TLF).•This is the first study (n = 33) to describe the safety and longer-term outcomes of deliberate SVG closure to mitigate this risk.•In a selected population, we found that SVG closure was safe and associated with a high success rate (97.0%).•Over a mean follow up of 602 (± 393) days from the date of SVG closure, the incidence of TLF of the reconstructed native vessel was 9.1% (n = 3).•Our results call for larger randomised trials to establish the benefit of this approach.